1. Sleep disorders in children
Dr Scott Burgess PhD FRACP
Paediatric Respiratory and Sleep Physician

2. Outline / Learning objectives:
Be able to describe the
Pathophysiology
Symptoms
Possible consequences
Investigation (including role of sleep studies) and
Management of OSA in children
Gain and understanding of common non-respiratory sleep problems in children, in particular
Sleep onset associations disorder in young children
Sleep phase disorder in teenagers
Questions?

3. Why worry about sleep problems?
Common – up to 30% of children are reported to have sleep problem
Important – can impact on...
Behaviour
Development
Growth
Medical well-being
Adverse impact on parental mental health
Treatable – GPs have a crucial role to play.

4. Obstructive sleep apnoea
OSA is characterised by:
recurrent episodes of partial or complete upper airway obstruction during sleep
disruption of normal gas exchange (intermittent hypoxaemia or hypercapnoea)
sleep fragmentation.

5. Obstructive sleep disordered breathing
Primary snoring
Increased upper airways resistance
Mild OSA
Moderate OSA
Severe
OSA

6. Frequency of SDB Snoring is a frequent symptom in children
Approximately ¼ of children snore intermittently
Habitual snoring (loud snoring reported to occur three of more times per week) reported by 10% parents
OSA affects approximately 2-3% of children.

7. Pathophysiology
OSA is associated with narrowing or collapse of the upper airway during inspiration. Typically at the level of the soft palate and adenoids (Isono, Shimada et al. 1998).

8. Predisposing factors (1)
Sleep state: REM sleep is associated with loss of pharyngeal muscle tone and a change in breathing
Adenotonsillar hypertrophy: growth of adenoids and tonsils relative to the airway, 2-8 years
Shape, size and collapsibility of the airway: individual variation in the size and collapsibility of the airway, heritable factor
Exposure to cigarette smoke and recurrent viral URTIs
Puberty: following puberty males developing longer upper airway, males > females post puberty.

9. Predisposing factors (2)
Arousal threshold and breathing control: mechanoreceptors in the upper airway stimulated by increased respiratory effort cause arousal during apnoea. Blunted in children with OSA
Medical conditions and syndromes may be associated with decreased airway tone and calibre (eg Down syndrome, Prader Willi, craniofacial abnormalities for example Pierre Robin)
Medications and alcohol can reduce airway tone and respiratory drive
Obesity is associated with increased adipose tissue in the neck, decreased lung volumes and diaphragm excursion when supine
Obesity may even blunt respiratory drive normally stimulated by hormones such as Leptin.

10. Symptoms of OSA Snoring Snorting
Laboured breathing / paradoxical chest wall movement
Witnessed apnoeas
Sweating
Restless sleep
Mouth breathing
Sleeping with neck extended or other usual postures
Hyperactivity, behavioural and cognitive problems
Sleepiness.

11. Neurobehavioural consequences
There is evidence that children with OSA have more behavioural problems than controls
Poor attention
Concentration
Hyperactivity
Aggressive behavioural
Moodiness
Poorer academic performance
Reduced scores on psychometric testing (IQ) in school aged children.

12. Cardiovascular complications
Episodes of obstruction are associated with autonomic activation
Some, but not all studies, have reported an increase in systolic blood pressure
Pulmonary hypertension and right ventricular strain is a risk factor in severe OSA
Weak risk factor for metabolic syndrome and cardiovascular disease
Combination of OSA and morbid obesity is an increasing concern in relatively young children.

13. OSA Diagnosis
Both history and examination do not accurately predict sleep study findings:
Illicit the history of above symptoms
Video recording of snoring and apnoea
Examination for nasal disease and increased tonsils
Consider in obese children and those with strong family history
Remember OSA in children with disorders of tone or upper airway.

14. Remember the nose...

15. What is a sleep study?

17. Treatment of OSA
Medical treatment of nasal disease: Nasal steroid +/- Singulair
Weight loss
Cigarette smoke exposure
Improve behavioural sleep problems
ENT surgery: T’s and A’s, or other surgery
CPAP – second line
Other:
Bi-level (CPAP > 15cm, mixed disease)
Maxillary expansion
Tracheostomy.

18. Non-respiratory Sleep problems
Inadequate sleep
Behavioural insomnia of childhood
Nightmares / bad dreams / night time fears
Parasomnias (night terrors, sleep walking)
Sleep phase syndromes
Psychophysiological insomnia
Narcolepsy
Restless legs syndrome.

19. How much sleep do children need. Iglowstein. Pediatrics. 2003
How much sleep do children need? Iglowstein. Pediatrics p302 Lot of individual variation, below are averages
Age (years)
Total Sleep
% having day nap
0.5
14.2
100 1
13.9
1.5
13.6 2
13.2 96 3
12.5 87 4
11.8 50 5
11.4 35 6 11 8 7
10.6
10.4 9
10.1 10
9.9
9.6 12
9.3 13 14
8.7

20. Behavioural problems: Is it a problem to them?

21. Most common behavioural problems
Sleep onset association (SOA)
Refers to a requirement by the infant or child for certain things to be happening as they go off to sleep
Interferes with their ability to independently go to sleep
Includes: being fed or patted to sleep, parent being present
Parents commonly complain that their child wakes more frequently during night
Normal children wake multiple times overnight
But can put self back to sleep
SOA – child cries until association is repeated
Limit setting type: Thus typically involves difficulties getting the child to go to bed and curtain calls.

22. Routines and sleep hygiene
Set a bedtime that will allow adequate sleep duration
Consistent routines
Should be clear to child when bedtime is coming up
Consistent from night to night and between carers
Environment: having TV in the child’s room and iPADs have been associated with increased difficulties falling asleep and less sleep time per night
Avoid caffeine containing drinks (USA 18% of preschoolers and 28% of younger school aged children drink at least one caffeinated beverage per day)
Quiet activity before bed eg looking at picture book or reading.

23. Sleep association
Graduated withdrawal (controlled crying) vs extinction
Need to have a plan
Need to agree on a plan
Need to be consistent
Start at beginning of night
Repeat during night and day naps
Monitor progress
Should see progress over days
Adjuncts: Melatonin 1-2 mg 30 minutes before bed.

24. Delayed sleep phase disorder
Second most common sleep disorder in adolescents (following inadequate sleep)
5–10% of adolescents
Persistent delay of at least 2 h beyond the desired bedtime, resulting in disruptions to the adolescent’s functioning
Trouble falling asleep (not anxious or worrying) but once asleep sleeps well and has trouble waking in time for school
Melatonin (Circadin) 2mg 45 minutes before bed and natural light at ideal wake up time
Need to be consistent
If extreme may need to move back slowly.

25. Resources Triple P (Positive parenting program)
Parenting and Family Support Centre, UQ, Ph
Child Health Nurses and Early intervention service
Ellen Barron Centre – public inpatient unit (PCH)
North West Private Hospital – Brisbane Nurture Centre
Q-CLASS (
Suresh and Scott
Beth Shirley – GP with interest in infant sleep / settling
Fiona Hudson – Psychologist with interest in sleep
Wesley sleep studies – short waiting list and covered by private insurance.

26. Questions?